SNF Case Manager
4 weeks ago
Job Summary
Alta Hospitals is seeking a highly skilled SNF Case Manager to join our team. As a key member of our healthcare team, you will be responsible for coordinating daily Inpatient/SNF services, including assessments, treatment planning, monitoring, evaluation, documentation, and discharge planning. You will work closely with Medical Directors, facility staff, and hospitalists to ensure the highest level of care is provided to our patients.
Key Responsibilities
Effectively manage patients to ensure the appropriate level of care is provided, utilizing the right tests and diagnostics in the right facilities. Communicate effectively with facility staff and hospitalists to gather clinical information and provide timely and accurate responses to requests. Update clinical information in the electronic medical management record system with treatment plans, objectives, results, and next steps. Document all information accurately with approved criteria, utilizing the goal length of stay. Initiate and continue direct communication with healthcare providers involved in the care of the member, including the IPA or Hospitalist Group if applicable, to obtain complete and accurate information. Apply appropriate benefits and utilize current approved criteria along with clinical experience to make authorization decisions. Identify cases not meeting criteria and provide clinical information and rationale to the Medical Director for review and determination. Actively participate in daily rounds with current and accurate clinical information.
Develop and implement timely denial letter language and member/provider notification regarding Medical Director's review determination. Identify and refer cases appropriately for CCS, High Risk, Hospice/Palliative, SNF, QI, and Disease Management, per policy, and document referral in case files. Refer cases to the Medical Director as appropriate for denial. Anticipate and initiate discharge planning within 24 hours of admission, complete post-discharge call within 24-48 hours of acute discharge or SNF, to identify barriers and prevent readmission. Identify post-discharge care needs and refer to the appropriate outpatient programs and/or providers. Interact with hospitalists, facility staff, and patients daily to evaluate plan of care, including discharge planning, to determine that patients are receiving quality care and appropriate discharge disposition. Apply medical knowledge to authorize outpatient services as an alternative to hospitalization when appropriate. Identify and report under and over utilization of medical services, delays in service by hospital or treatment, and quality care issues to the Medical Director, and/or the QI department. Actively participate in internal quality and workflow enhancement projects, and other duties as assigned. Identify and report departmental operational issues and resource needs to the appropriate management personnel.
Requirements
Three to five years' experience in a Medical Group or Health Plan setting with strong clinical skills and critical thinking. Four years of experience in a managed care setting. Experience with Microsoft Office Word required. Recommend but not required, knowledge of NCQA, Medicare, Health Plan, DHS, and State standards and other regulatory requirements. Make independent decisions. Knowledge of nationally recognized criteria InterQual, etc. Maintain strong working relations with internal and external customers. Effectively articulate clinical and non-clinical information to persons of all levels. Communicate positively and effectively. Maintain member confidence and protect operations by keeping claim information confidential in compliance with HIPPA requirements. Graduate of accredited nursing program. RN active unrestricted license.
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